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ubmitted Properly Completed.Be Sure To sign r ne <br /> Applications Will Be Process"�When S ..p►+ �a••�• <br /> 1�0, APPLICATiON ' <br /> FOR OFFICE USE: <br /> (For Non-Transferable,'.Revrsl:atile;Suspendable) PUMP&WELL <br /> ENViAONMENTAL HEALTH'PERMIT <br /> �'`� u �+ S l VATER QUALITY �-�/� ..'S"D— O(�4,--O L <br /> application is <br /> 'deicribe <br /> (COMPLETE IN TRIPLICATE) ,�Jt to <br /> Application is hereby made tothe San Joaquin Locain ncehNos11862 andthe rules o nd e tulatons oftthe Sn Joaquin Loccal Heat Distryc.This <br /> ril�.de in compliance with San Joaquin County•ri <br /> Exact Site Address <br /> .Phone <br /> a <br /> Ovtrne(s.Name <br /> Address r / License# Business:Phone • . • "• _ ''��'�J <br /> Contractor's Name �• <br /> `Emergency�Phone. <br /> Contractor's Addresses No j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ❑.:-�„'_ _ <br /> TYPE OF WORK (CHECK): -'NEW 1NELL19"` `DEEPEN❑— -'`RECOh1DITION❑ DESTRUCTION r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑. OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ c. Pit Privy <br /> Sewer Lines Other <br /> DISTANCE TO NEAREST: Septic Tank �.� �. Cesspool/Seepage Pit' <br /> Sewage Disposal Field <br /> Property Line <br /> Private Domestic Well Public Domestic Well - <br /> INTENDED USE TYPE OF WELL <br /> Dia. of Well Excavation- <br /> 13 <br /> ❑ BLE TOOL <br /> DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing " f f. <br /> ❑ DOMESTIC/PUBLIC ❑'DRIVEN t' <br /> GRAVEL PACK. _ Depth of Grout Seal <br /> O IRRIGATION _ _ - - Type of Grout ` <br /> C3 CATHODIC PROTECTION ROTARY - J/ f,f V')- �. <br /> ❑ OTHER Other information ' <br /> ❑ DISPOSAL Surface Seal Installed By:. <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: El State Work Done <br /> ❑ <br /> PUMP REPAIR: State Work Done Approximate Depth <br /> DESTRUCTION OF WELL-. Well Diameter <br /> Describe Material and Procedure.. <br /> I hereby certify 1hat'l have prepared this application and that the work Will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> that in the performance of the <br /> or which thi prm <br /> Home owner or licensed agent's signature cert such mannerlas to ecomeifies the folowing'."Ifsub act to workman <br /> compensatti of laws of Ca!forn a.t <br /> is issued, I shall-not employ any person <br /> Contractor s hiring orsub-contracting signature certifies the following'."I certify that in the performance of the work forwhich this <br /> permit is issued,-I shall employ persons subject to workman's compensation laws of California." <br /> I wil calf for a Grout 1pspe n prior.to grouts g and a final inspection. fG? <br /> Date: <br /> % itle(-� <br /> Signed X (DrawV11PIL on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �/ Date <br /> Application.Accepted By <br /> Additional Comments: Phase Ill Final Inspection <br /> Fpirtaso G� Inspection Date <br /> ate 6' inspection By <br /> Inspection By <br /> REMIT <br /> . Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 July 1 &Received By July 3t <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE 'EXPLANATION DATE DATE REMITTED AMOUNT <br /> O - <br /> FEE. �I - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> -OTHER <br /> OTHER <br /> rn `permit <br /> rmit No.d / Issuance Date Mailed <br /> Date Delivered <br /> Receipt No._ - ' <br /> Received by - - 1601 E.HAtELTON AVE.,P.O.Box 2009 S70CKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />